Treatment options for an anxious, suicidal patient with a history of Lyme disease
One of the most challenging aspects in treating Lyme disease patients lies in the ability to decipher whether a patient’s current health complaints could be attributed to a past Lyme infection. This challenge is made even greater when a person has co-existing psychiatric symptoms.
by Daniel J. Cameron, MD MPH
In an article entitled “New-onset Panic, Depression with Suicidal Thoughts and Somatic Symptoms in a Patient with a History of Lyme Disease,” researchers highlight the complexity of evaluating and treating a patient with a history of suspected Lyme disease who presented with neuropsychiatric symptoms. 
The authors, Amir Garakani and Andrew Mitton, discuss the importance of considering cognitive behavioral therapy (CBT) intervention for individuals who suffer from chronic illness associated with mood symptoms.
Garakani et al present the case of a 37-year-old employed man, who was admitted to an emergency department with new-onset panic, depression with suicidal thoughts and somatic symptoms, which included a 3-month history of palpitations, tremulousness, chest pressure, choking sensation, and an intense fear of dying.
The patient also reported back pain and muscle spasms, weakness and tingling in his arms and legs, general fatigue, poor sleep, low energy, loss of interest in his job and social activities, loss of appetite, and a 10-pound weight loss. He remained ill despite being treated with anti-depressants and anti-anxiety medications for the previous two months.
He reported a history of Lyme disease two years prior when he developed fatigue, tinnitus, headaches, fever, and other flu-like symptoms a month after removing a tick off his leg. The patient had a positive Lyme ELISA antibody. His symptoms were said to have resolved after a three-week course of doxycycline 100 mg twice daily. However, he continued to suffer from anxiety and neuromuscular pains and visited the emergency department several more times.
The patient was eventually admitted to inpatient psychiatry for depression and suicidal ideas, and prescribed anti-depressants, anti-anxiety medications and a beta-blocker. Nevertheless, he continued to complain of cramping, flank pain, fatigue, arthritic knee pain, anxiety, poor attention and focus, and panic.
Garakani et al reports, “He was very forgetful at home and would often not recall having taken his medications or where he had left common household items,” and he was “frustrated by the persistence of his neurological symptoms which further contributed to his hopelessness and passive thoughts of dying.”
On Day 8, after his mood had improved, the patient was discharged. At this time, the man still complained of fatigue, weakness, back and leg spasms, “shooting pains” in his hands, and pain and tingling “rising up” in his body, reports Garakani et al.
Despite having visited multiple internists and neurologists, the man continued to have cognitive deficits upon discharge. Evaluations included negative Lyme disease Western blot tests.
The patient continued to seek treatment with other specialists and was diagnosed with Lyme disease. He was tested at IGeneX Laboratories in California. Results indicated he was positive for Borrelia on Bands 31 and 34 and Babesiosis. These Bands have not been included in the CDC seroepidemiologic criteria. There is no record of whether the treating physician used clinical judgment or testing in making the diagnosis.
After a 6-month course of oral antibiotics, including 3 months of tetracycline and 3 months of azithromycin and fluconazole, the man’s cognitive deficits improved. He no longer reported having panic attacks or periods of hopelessness or suicidal thoughts, and doctors were able to stop his psychiatric medications.
The authors point out that following treatment for Lyme disease, the patient still felt “despondent and frustrated by the lack of improvement in his physical symptoms.” He had been forced to leave his job and go on disability, and he continued to have fatigue, weakness, low energy, pain and spasms in his back and upper legs, and nonspecific joint pain, states Garakani.
Garakani et al did not present rationale for the option to retreat the man with antibiotics including:
- Chronic Lyme disease (CLD) is considered controversial;
- Conflicting evidence on whether physical symptoms can persist in Lyme disease patients after they’ve been treated with the recommended course of antibiotics;
- Validity of Western blot bands 31 and 34;
- The possibility of “Organically Unexplained Symptoms”;
- The idea that patients can “develop illusory patterns of perception when they lack control” over chronic health problems. (An idea posited by Auwaerter and Melia, in referencing Whitson and Galinsky.)
Garakani et al also did not mention that:
- CLD controversy centers on diagnostic terms and on treatments;
- Four NIH sponsored trials documented the severity of physical symptoms associated with Lyme disease;
- Validity of even CDC recognized bands;
- Absence of a valid test for “Organically Unexplained Symptoms”;
- The idea posited by Auwaerter and Melia has not been validated.
The authors also failed to mention the option of treating the 37-year-old man for Babesia, despite his history of having a positive Babesia test.
As early as 1996, 10% of patients with Lyme disease in southern New England were found to be co-infected with Babesia. Having the co-infection can increase the severity and duration of illness in patients. According to the study, co-infected patients were more likely to experience fatigue, headaches, sweats, chills, anorexia, emotional lability, nausea, conjunctivitis and splenomegaly.
Patients with co-infections often require a mixture of antibiotics. A combination of azithromycin and atovaquone has been effective in treating patients co-infected with Lyme disease and Babesia.
The report did not mention the possibility of treating the 37-year-old man with intravenous (IV) antibiotics. The spirochete causing Lyme disease can cross the blood brain barrier (BBB) leading to chronic neurologic Lyme disease and Lyme encephalopathy. Intravenous ceftriaxone has been effective in treating chronic neurologic Lyme disease and Lyme encephalopathy by crossing the BBB.
Garakani et al case study offers insight into the complexity of evaluating and treating an individual with neuropsychiatric symptoms with a history of Lyme disease. Although the evaluation and treatment may have been well thought out, additional treatment options could have been discussed with the patient. The 37-year-old man might have benefited from a concurrent combination of treatment for Lyme disease, along with cognitive behavioral therapy.
- Garakani A, Mitton AG. New-onset panic, depression with suicidal thoughts, and somatic symptoms in a patient with a history of lyme disease. Case Rep Psychiatry, 2015, 457947 (2015).
I received the 2nd moderna vaccine. The next morning I had a stiff neck and back and headaches. Also, a lot of anxiety. I was treated for lyme 5 years for over 2 years. My symptoms approved. Could the vaccine make my lyme symptoms reappear? Thank you
The symptoms following a COVID-19 can resemble symptoms of Lyme disease even in patients without a history of Lyme disease. I have patients and readers of my blog who are sharing their experience. It is hard to know what symptoms are from the COVID-19 vaccine or a flare-up of Lyme disease. Some Lyme disease patients face flare-ups with or without a vaccine. Many of my patients and readers have suffered from immune issues related to Lyme disease. My patients and readers are only making these tough decisions given the severity of COVID-19 in some individuals.
Caught Lyme on east coast 2009. Was prescribed 10 days of doxycycline right when I found the bullseye. (4 days after tick removal). Physical symptoms went away within 2 weeks. A year later, came down with OCD symptoms (first time ever- I was 43 years old). Had a death in the family during that year as well and attributed OCD to that. But wonder if it could be Lyme. Last Lyme test I had was in 2015 I believe and it was still showing positive for IgM but not IgG. (So looks like recent infection in my blood work). Could Lyme be causing my mental health issues or just coincidence? Therapy has helped some, SSRIs made me worse, but a decade later, I’m miserable emotionally. Doctors just chalk it up to emotional trauma but I can’t understand why I can’t seem to get better., and why such a late onset in life. I don’t have any physical symptoms.
I don’t know where to turn. I live in the Midwest so very few deal with Lyme much. I tried someone in Maryland and they just said “well sometimes you don’t seroconvert, keep an eye on your heart just in case”. Another doctor asked if maybe I had syphilis. (That one cracked me up. I know you can get a false positive for Lyme with syphilis, but I found it funny).
Any advice would be so appreciated.
I find it difficult to determine if a tick-borne illness is part of the problem. The tests are not as reliable as I would like. An IgM western blot test can come and go in some patients without ever developing an IgG western blot test. I advise my patients to continue their psychiatric care while looking a second time at a tick borne illness.
Tet books from Dr. Jay Davidson, Dr. Horowitz. Lookup Dr Buhner, join fb group “Microbe Formulas Detox Heroes”. Join Mivrobe Forumulas website for a wealth of videos. For my daughter the physical healing began with functional medicine. Find a lyme literate medical doctor (LLMD) is another option
Thank you for what you do for the Lyme community! I was diagnosed with Babesia Duncani and Lyme by IGENEX labs in Feb 2020. I started treatement the first week of March with DOXY Azithromycin Ceftin and Mepron. My symptoms felt more neurological in June and my LLMD tested me for BART through Galaxy and I was PCR positive. We then stopped my babesia treatment and focused my regiment on Bart and I tested clear of BART in August and September through IGENEX W-Blot, Galxay tripple draw, and T-lab. However My babisia titer was higher than in Feb (340). I was feeling good through September- October so I was taken off antibiotics. In late October I started to develop that odd neurological anxiety. My symptoms now are anxiety, shortness of breath, slight heart palpitations, depression, neurological slight cognitive impairment. My LLMD thinks that I have lyme or BART persisters and is putting me on Horowitz’s Double Dapsone protocol. (Dapsone build to 200MG a day, Minocycline, Bacrtrim DS, Oregano oil, AlliMax, and I will take 50mg of Methylene blue a day for the last 4 weeks of treatment). My question, Will this treatment also address my Babesia Duncani? Should I address Babesia prior to heavy Bart and Lyme protocol?
I do not believe your proposed combination works for Babesia. I typically return to Babesia before the new protocol. Other doctor disagree.
My 28 year old daughter is having panic attacks almost daily. She experienced childhood trauma and was also diagnosed with Lyme disease in 2015 but is not able to complete treatment due to the onset of anxiety and panic around treatments and her physical symptoms. Can you recommend an inpatient treatment center that can address both the mental/emotional and physical issues?
I work with complex presentations in my practice. I understand how hard it is to find the right in-patient program. I don’t know of any programs. I have patients that have had an in patients experience but they have found it difficult to find a doctor with experience treating Lyme disease with psychiatric issues.
My husband was diagnosed with Lyme and Babesia about 9 years ago. He has been undergoing treatment ever since. He changed providers last year and his new provider wants him to be re-tested by Igenex. I’m concerned that if the tests are only IGG positive she will not continue to treat him. Are you aware of any methods to “provoke” activity to get a positive (IGM) result? Thank you!
I don’t have a way to provoke an IgM. Some doctors dismiss the IgM if someone has been ill for more than a month. Your doctor will have to use clinical judgment at the Igg stays positive even if the infection has resolved. Call my office at 914 666 4665 if you have any questions.